Musculoskeletal Conditions in Dentistry:
The Most Common Disability, The Most Difficult Disability Claim
One in four workers will suffer a long-term disability during his or her career. For dentists, whose work involves musculoskeletal strain, this number is even higher. Even with ergonomic accommodations, many dentists become disabled for some portion of their career. Most dentists understand this risk and purchase disability insurance to protect themselves; however, few realize that claims for musculoskeletal conditions are the most frequently denied by insurance companies.
ADA Income Plan Data from 2001-2007 shows that musculoskeletal disorders of the spine, shoulder and wrist made up a full 37 percent of dentists’ disability claims for those years. In 2009, nearly one-half of all open claims paid to disabled dentists under the ADA Income Plan were for back and cervical disorders, arthritis, and wrist issues.
The Progression of Musculoskeletal Disorders among Dentists
Studies reveal that a majority of dental students experience chronic musculoskeletal pain by their third year of dental school. The pain can progress throughout a dentist’s career. In fact, the Institute of Dental Ergonomics found that three in four dentists suffer from musculoskeletal disorders. Similar studies estimate the percentage of dental professionals suffering from general pain in the back, neck, shoulder or arm as high as 81 percent. This results in nearly half of all dentists having to shorten their work hours at some time during their career.
Mechanisms Leading to Cumulative Physiological Damage
There are many parts of the dentist’s job that contribute to the prevalence of musculoskeletal and repetitive motion disorders. One of the main sources of stress on a dentist’s body is prolonged static postures, or PSPs. For most dentists, PSPs are an unavoidable part of the job. Even in ergonomically optimal PSPs, more than half of the body’s muscles are contracted statically, with little to no movement of the vertebral joints. PSPs can result in muscle ischemia and joint hypomobility, among other problems. For example, the static seated postures required in dental work can also cause the lumbar curve to flatten, which in turn causes the nucleus in the spinal disk to migrate posteriorly toward the spinal cord. Over time, the posterior wall of the disc becomes weak, often causing herniation.
Carpal tunnel syndrome is another condition that plagues dentists. Contributing ergonomic factors for carpal tunnel syndrome include repetitiveness of work, forceful exertions, mechanical stress, posture, temperature and vibration.
Musculoskeletal conditions are especially debilitating for dentists, whose daily activities require both physical and mental agility. Moreover, dentists are often required to continue performing the very tasks that resulted in, and increase the negative impact of, the condition. As a result, dentists suffering from conditions such as disc degeneration, chronic pain, and carpal tunnel syndrome often find that they can no longer practice, and must therefore file a claim for disability insurance.
Disability Insurance Claims for Musculoskeletal Disorders Receive Heightened Scrutiny
Unfortunately, dentists are particularly vulnerable to having their disability claims denied, as insurance companies are aware of the fact that proving up a musculoskeletal disorder, including its full occupational impact, is largely subjective. In other words, a dentist may suffer from debilitating pain, yet the objective medical evidence either fails to reveal the injury or shows an injury that appears less severe than the level of pain would indicate.
Claim Analytics, a provider of predictive modeling to the insurance industry, recently published a study showing that upwards of 30% of all disability claims are denied. These figures include claims for objective conditions such as cancer and physical injury, so they don’t give a complete indication of how many subjective claims are denied by each insurer. However, insurers do publish “recovery rates” for each type of claim. Recovery rates are determined by the percentage of disabled policyholders who, according to the insurer, “recover” from their disability within twenty-four months, and thus no longer qualify for disability benefits. The average health of policyholders is generally consistent across insurance companies, thus the differences in recovery rates between insurers most likely reflects differences in the ways these insurance companies evaluate claims internally.
For musculoskeletal claims, there are large differences in the recovery rates among the various insurance companies. This suggests that an insurer’s internal claim evaluation criteria, rather than the actual underlying medical condition, most heavily affect the outcome of a musculoskeletal claim. Furthermore, this great disparity in recovery rates amongst insurers shows that insurance companies are highly inconsistent when it comes to approving claims for musculoskeletal conditions, and claim denials often correlate with corporate culture affecting the aggressiveness of claim administration, the financial well-being of a company and a desire to increase the bottom line.
With regard to claims involving musculoskeletal conditions, insurance companies often try to take advantage of the lack of objective proof, and variously assert that the legitimately disabled dentist is lying or malingering, making a lifestyle choice, only interested in secondary gain, unmotivated to work and/or dissatisfied with work, or “embracing the sick role.” The companies’ investigators then try to gather other evidence that the disabled dentist is engaged in activities inconsistent with impairment, soliciting opinions from former employees, conducting interviews and surveillance, and reviewing the public record (including social media sites). These snippets of information, taken out of context, present the picture that a cost-cutting insurance carrier wants – that the dentist is not disabled and does not qualify for benefit payments. Sadly, the denial of legitimate claims is prevalent and is devastating for a dentist who can no longer practice, who has paid disability insurance premiums for years, and who now depends on income from his or her policy.
Counteracting the Unfair Review of a Musculoskeletal Claim
One way to address an insurance company’s claimed skepticism of a musculoskeletal claim is to keep detailed records of the condition from the very beginning. Dentists should consult a physician when they start experiencing symptoms, and should make sure that they thoroughly explain their symptoms, including the full extent of any occupational impact. That way, the dentist’s treating physician can make sure the condition is adequately documented in case the dentist needs to file for disability insurance benefits at some point in the future.
A dentist with a musculoskeletal condition should also undergo the most advanced testing available for the particular condition. If a claimant can provide objective testing that shows the existence of a musculoskeletal problem, the insurance company is more likely to approve the claim. For example, if a dentist is suffering from carpal tunnel syndrome but an electrodiagnostic test doesn’t definitively show that CTS exists, the dentist should ask for a neuro-selective current perception threshold test. This more advanced testing provides reliable objective results that other testing may not.
Another way to bolster a musculoskeletal claim is to find a well-regarded treating physician. If a physician is a known expert in his or her field, the insurance company will be less able to question his or her findings. In Arizona, for example, Barrow Neurological Institute and the Mayo Clinic both have internationally renowned specialists that treat musculoskeletal conditions.
Finally, dentists with musculoskeletal claims should be aware of how they are presenting themselves in public. Though even the most disabled person has moments of joy in life, insurance companies often expect disability claimants to be in state of perpetual helplessness. For instance, if a insurance claims administrator sees Facebook pictures of a dentist enjoying a birthday party or surveillance footage of the dentists taking a light walk in the park, those images can be interpreted as evidence that the dentists isn’t totally disabled.
Unfortunately, disability claim administration is designed to be extremely complicated for the claimant, and involves numerous timing issues and hurdles that are best discussed with a disability insurance attorney well in advance of filing a claim. If dentists are aware of the risks of their profession, understand how to properly document symptoms, and consult with an experienced attorney should they need to file for disability insurance benefits, they may be able to overcome the odds when it comes to musculoskeletal claims.
* Edward O. Comitz, Esq. heads the Health and Disability Insurance Practice Section at Comitz | Beethe. Mr. Comitz has extensive experience in disability insurance coverage and bad faith litigation, primarily representing medical and dental professionals in reversing denials of their disability claims. Comitz | Beethe has offices in Scottsdale (Phoenix), Tucson and Flagstaff, Arizona.
The information in this article has been prepared for informational purposes only and does not constitute legal advice. Anyone reading this article should not act on any information contained therein without seeking professional counsel from an attorney. The authors and publisher shall not be responsible for any damages resulting from any error, inaccuracy, or omission contained in this publication.
 Social Security Administration, Fact Sheet March 18, 2011.
 Kristina Lynch, My back is hurting my practice, Part I, AGD Impact, Feb. 2006, http://www.agd.org/support/articles/?ArtID.
 Bethany Valachi and Keith Valachi, Mechanisms leading to musculoskeletal disorders in dentistry, JADA, Oct. 2003, at 1344 [hereinafter Mechanisms].
 Curt Hammann, et al., Prevalence of carpal tunnel syndrome and median mononeuropathy among dentists, JADA, February 2001, at 163.
 Bethany Valachi and Keith Valachi, Preventing musculoskeletal disorders in clinical dentistry, JADA, Dec. 2003, at 1604 [hereinafter Preventing].
 Id. at 1608.
 Id. at 1605.
 Hammann, et al., supra note 5, at 164.
 Claims Analytics, 2010 Long Term Disability Benchmarking Report.